Provider Demographics
NPI:1083788632
Name:NICLAS, TANIA M (PT)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:M
Last Name:NICLAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12799 ASPEN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7339
Mailing Address - Country:US
Mailing Address - Phone:801-254-6027
Mailing Address - Fax:
Practice Address - Street 1:3584 W 9000 S
Practice Address - Street 2:JORDAN VALLEY MEDICAL CENTER PHYSICAL THERAPY SUITE 102
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5710
Practice Address - Country:US
Practice Address - Phone:801-601-2309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6951Medicaid